NFN :: HRA

All enrollments must be directly through the National Fitness Network.

Print and then fax or mail this form to National Fitness Network. If you choose to pay by credit card, you may complete this form online and submit it electronically.

Fields marked with * are mandatory.

* First Name
* Last Name
* E-mail
* Social Security #
* Eligibility
* Primary Club Selected :
* Location/City
* State

* All memberships begin on the first of the month. Please start my membership on 1st

Home Address :

* Street

* City

* State

* Zip

* Home Phone

* Employer

* Job Title

Work Address :

* Street

* City

* State

* Zip

* Work Phone

* Fax Number

Additional Family Members to Be Added:

	Name	Relationship	Date of Birth
1.
2.
3.

* Type of account to be billed : Checking Visa MC Amex

NOTE : If using checking account you must fax or mail this form to us at:
National Fitness Network, P.O. Box 5329 Laurel, Maryland 20726, Fax (240) 568-0084.

Complete the following if using a checking account:

Bank Name

Account#

Routing#

Note: You must enclose a voided check with application.

Complete the following if using a credit card:

Name as it appears on credit card
Account# Expiration Date

There is a one-time enrollment fee of $49 for the primary applicant and $29 for each additional family member.

Enrollment form indemnification clause:

By authorizing below, I agree to abide by the Terms and Conditions, described herein, and the rules and regulations of each participating health club I utilize. I also understand that my account will be billed as described in the information I received with this Enrollment Form, and that there is a minimum commitment of nine months. Prices are not guaranteed and are subject to change. I understand that the National Fitness Network will charge a $10.00 late fee for any checking account or transasction that is denied by the financial institution which I have designated.

I further acknowledge that all information provided is accurate to the best of my knowledge. The sponsoring organization/group, all participating health clubs, and Mid-Atlantic Fitness Network, Inc. DBA National Fitness Network, shall be held harmless of any liabilities resulting from my choice to enroll and participate in the Fitness Network.

Signature _________________________________ Date ____________